Should teardrop breast implant be placed by armpit incision or infra-mammary incision?

Question

I'm a thin, flat chest woman. It is said that I should have teardrop implant so that the breast has natural look. Should teardrop breast implant be placed by armpit incision or infra-mammary incision?

Daniel Barrett, MD · Answer

Dear LauraAnnie,I tend to prefer the periareolar incision because its the most well hidden. There is a natural border between the areola and the rest of the breast skin the hides the incision extremely well. You have to be completely naked to see it vs other incisions like transaxillary and inframammary are visible in clothing such as sleeveless shirts and bikini tops when extending your arms up. I've also noticed increased rates of bottoming out with inframmary incisions that is not reported. Transaxillary implants are always wide in appearance because the surgeon is not able to dissect medially enough to provide better cleavage. Ultimately, I can perform any of the incisions but I recommend the periareolar. There is no difference in sensation because the nerves that control nipple sensation come in laterally from the back and injury to them occurs when surgeons dissect to far laterally which is why transaxillary incisions have the highest nipple sensation disruption. There is no difference in breast feeding ability. One study did show a slight increase in capsular contracture with use of periareolar but that study was small and did not incorporate modern techniques such as below muscle placement, keller funnel usage and triple antibiotic irrigation. Daniel Barrett, MD, MHA, MS 
Certified, American Board of Plastic Surgery  
Member, Am. Society of Plastic Surgery

Urmen Desai, MD, MPH, FACS · Answer

The IMF incision is associated with the least amount of complications, both short term and long term.  The implant selection should be based on a combination of your desired size, soft tissue dynamics, breast base diameter and skin elasticity.  I recommend an in-office examination as well as a detailed discussion with a surgeon who you are comfortable with.   Finally, make sure your surgeon is a Double-Board Certified Plastic Surgeon certified by the American Board of Plastic Surgery (ABPS), a member of the American Society of Plastic Surgery (ASPS), a member of the American Society of Aesthetic Plastic Surgery (ASAPS), and a fellow of the American College of Surgeons (FACS).Best,Dr. DesaiBeverly Hills Institute for Aesthetic Plastic SurgeryHarvard Educated, Beverly Hills & Miami Beach TrainedDouble Board-Certified, Double Fellowship-Trained Beverly Hills Plastic Surgeon

Donovan Rosas, MD · Answer

The choice of incision in the setting of breast augmentation is one which is made jointly by both the patient and the surgeon. Surgeons typically have their preference as do patients. 
Your options include-
The DIRECT approaches:
-IMF (fold)- (+) popular, direct access with good visualization, if placed appropriately it is well tolerated and well camouflaged; (-) the scar can migrate as the fold descends with augmentation, the incision can be misplaced
-Infrareolar- (+) commonly used alternative to the IMF incision, the location is more consistent and predictable than the IMF, especially useful in those patients with a poorly defined fold; (-) there is a limitation based on the size of the areola (smaller areolas will limit incision size and thus impact visualization), this technique is also associated with slightly higher rates of contracture (due to the contention that there is low grade contamination associated with passage through breast tissue).
The INDIRECT approaches:
-Transaxillary (armpit)- (+) avoids a scar on the breast mound but must be performed endoscopically as there is no direct visualization of the pocket during dissection otherwise; (-) can be limiting with regards to implant size and type (although the Keller funnel has helped); saline is preferred, however, smaller silicone devices with a funnel are possible; form stable implants cannot be placed via this indirect route.
-Transumbilical (belly button)- (+) avoids a scar on the breast mound; (-) no direct visulization of the pocket, saline implants only.
The direct approaches remain the most popular with the IMF approach most commonly used. With regards to tear drop shaped devices orientation is paramount. Thus the direct IMF approach is preferred for orienting a shaped device.
Ultimately, no approach is perfect. They are different as is each surgeon. The incision decision is best made in concert with your board certified plastic surgeon (ABPS).

Gerald Minniti, MD, FACS · Answer

Hello,The IM incision is the right incision for all implants, not just shaped. Bacterial contamination of breast implants is the cause of the most common complication of breast augmentation, capsular contracture, and is probably the cause of the least common complication, BIA-ALCL. IM incisions help to reduce the risk of implant contamination, and is necessary for shaped implant placement. Best of luck!

Ronald J. Edelson, MD · Answer

it is difficult to orient teardrop implants accurately through a transaxillsry incision.  I’m not a fan of teardrop implants overall.  There was recently a study in which plastic surgeons tried to guess if other surgeons patients had found or teardrop implants, including being able to feel them.  They couldn’t tell which was which!

Michelle Hardaway, MD · Answer

Placing an anatomical or tear drop implant through an infra-mammary incision is often better to insure correct orientation of the implant. These implants are textured and proper orientation is important.

Ajay Mahajan, MD, FRCS (Plast) · Answer

There are different approaches to insert an implant in a breast augementation procedure. The resultant scars are either around your areola, in your axilla, at your belly button or in the crease under the breast, depending on the technique used. It is preferable to use the infra mammary approach that results in scars in the crease under the breasts. This approach helps precisely dissect the pocket into which your implant will be placed. This is very important factor in the aesthetic outcome of the operation. It also helps adjust the position of the inframammary crease that can change depending on the implant selected. Also,there is potentially an increased risk of infections in the trans areolar, axillary or trans umbilical routes. In the trans areolar approach the dissection is done right through the breast tissue thereby disrupting the milk ducts and nerves to the nipple. The dissection is carried out entirely under the breast gland in a infra mammary approach.The trans umbilical approach can only be used for saline implants.

Scott C. Sattler, MD, FACS · Answer

I've never understood the rationale for an axillary scar in breast augmentation surgery. We use a well concealed infra-mammary scar that is placed within the infra-mammary fold.

Eugene Kim, MD · Answer

I recommend an inframammary incision for shaped implants because it is difficult to orient the implant through an armpit incision.  If the implants is not placed properly, it can make the breast look crooked.

Mathew A. Plant, MD, FRCSC · Answer

Shaped, textured implants require a very precise pocket dissection which needs direct visualization. Most transaxillary procedures are done blind so it would be very difficult to ensure that the implant is placed properly and the pocket is tight enough to allow the proper healing that prevents rotation down the road. If you are going with someone who uses a transaxillary approach, make sure its an endoscopic assisted approach that allows them to actually see what they are doing. Hope that helps!

Should teardrop breast implant be placed by armpit incision or infra-mammary incision?

Answers (19)

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